Doctor, should you continue with ‘ct all’?

It’s a common practice among doctors and paramedical staff in India to use some abbreviations while documenting medical records. Writing detailed medical records, and that too for so many patients, is no mean task, ask any resident doctor in India. Some of the informal abbreviations used in medical records have been handed down by one generation of doctors to the next, and thus have become a sort of convention. All this was working out perfectly well for past so many decades because medical records were basically being seen and scrutinised only by doctors. But in the past one decade or so, medical records have increasingly come under scrutiny of the legal system, particularly due to increasing number of medical negligence related lawsuits. Abbreviations thus are no more just the innocent and convenient communication tools meant for doctors. The case I am illustrating today – The Medical Director, Amrita Institute of Medical Sciences and Research Centre & Ors. Vs Unnikrishnan & Ors. – clearly conveys that using medical abbreviations can be counterproductive for doctors and hospitals.

In this case, the patient, a 9 years old child, underwent ophthalmic surgery for squint. The patient suffered cardiac asystole towards the end of the surgery. Successful resuscitation was done but the patient continued to have episodes of asystole and bradycaria, for which pacemaker wire was placed. The patient subsequently expired while in the ICU.

Alleging medical negligence, the parents filed a complaint against the hospital & doctors in the District Consumer Disputes Redressal Forum (DCDRF). The District Forum upheld the claim of negligence and awarded a compensation of Rs. 6L with 12% interest from the date of order. Aggrieved by the order, the hospital filed an appeal in State Consumer Disputes Redressal Commission (SCDRC), which dismissed the appeal. A revision petition was thus filed in the National Consumer Disputes Redressal Commission (NCDRC).

The complainant’s allegations were as follows:

i) Negligence in anaesthesia administration, including pre-operative precautions

ii) No proper consent taken

iii) Manipulation of medical records

While defending themselves, the doctors stated that all pre-operative tests had been conducted. Also, a proper consent was obtained before surgery and all risks specific to squint surgery were explained to the parents. Glycopyrrolate was preferred over atropine for pre-operative medication because atropine increases heart rate which can be a problem during surgery. Glycopyrrolate also reduces salivation and is a well-accepted alternative for atropine. Glycopyrrolate was written as ‘glyco’ in the pre-operative notes due to lack of space on the sheet. A team consisting of Opthalmologist, Anaesthesiologist and Cardiologist had managed the patient, there were no lapses in the resuscitation steps and the parents were informed periodically about the condition of the patient. The petitioners also referenced to the report of expert committee which did not find any deficiency in service or negligence on the part of doctors.

After going through all the arguments, the NCDRC concluded as follows:-

a)—The consent obtained from the mother of the child was just a routine consent and not really an informed consent because the special risks involved in squint surgery were not explained in the consent. The DCDRF had also noted that the consent obtained from the mother looked merely ritualistic and not an informed consent.

b)—Although the anaesthesiologist claimed that retrobulbar block was given by the surgeon and hence the anaesthesia notes did not mention the retrobulbar block, the NCDRC observed that none of the three documents viz; the anaesthesia notes, the ophthalmic surgery notes or the physician’s progress notes had any mention of retrobulbar block. Hence, the NCDRC concluded that no retrobulbar block was given.

c)—From the oral arguments, NCDRC noted that the word ‘glyco’ was written instead of ‘glycopyrrolate’ in the OT record, and use of such abbreviation is misleading to the consumer fora. NCDRC stated that there are several meanings of the word ‘glyco’ and use of confusing abbreviations in medical records is deficiency in service. As per the NCDRC, even though glycopyrrolate is an acceptable drug, no other record was produced which could prove that glycopyrrolate was indeed administered.

Based on the above, the NCDRC dismissed the revision petition filed by the hospital, and upheld the earlier order of medical negligence.

So what do we learn from this case?

1)—Use of informal medical abbreviations should be avoided since they are likely to work against the doctors in medical negligence lawsuits.

2)—It must be noted that the conclusion drawn in the report of Expert Committee in a case of medical negligence is not binding on the consumer forum.

3)—An important point was made by NCDRC in this case, which is as follows – “No documentation or improper documentation means ‘no proof’. Thus, care is considered as not done”. It is therefore clear that verbal claims have little meaning if the same are not corroborated by flawless medical records.

4)—A routine consent may not be considered an informed consent. A legally valid written informed consent should discuss the risks that are specific to the surgery being planned.

William Osler once said -- “Medicine is a science of uncertainty and an art of probability”. I would like to say – “Higher the uncertainty of outcome, more likely is the probability of litigation and greater is the need for accuracy of medical records!”

Author:

Dr. Chandrashekhar Sohoni


(This write-up is only a general advisory and not a substitute for qualified legal opinion. Reader discretion is therefore recommended. If you find this write-up useful, please share it with your doctor-friends. TechnoScope Systems is a venture by doctors, for doctors. To know more about how we can assist you, please visit our website. You can write to the author at: sohonica@gmail.com)


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